Test 2: Trauma Flashcards
When did Connecticut’s trauma system begin?
October of ‘95
What are the criteria for a level 1 trauma center?
>1200 traumas per year
>240 admissions with injury severity score (ISS) > 15
Avg. of > 35 pts with ISS of > 15 seen by trauma panel surgeon
What is ATLS? when was the first class and when did ACS take it on?
Advanced trauma life support. first class 1978. ACS took on ATLS =1980
What is included in standard precaution?
cap, gown, gloves, mask, shoe covers and goggles/face shield
What is a quick simple way to assess a patient in 10 seconds?
identify yourself, ask the patient his or her name and what happened.
When assessing a patient, an appropriate response confirms what?
ABCD - patient airway, sufficient air reserve for speech, sufficient perfusion to permit cerebration, clear sensorium
In primary survey what are the ABCDEE?
A = airway with c-spine protection, B = breathing with adequate oxygenation, C = circulation with hemorrhage control, D = disability, E = exposure/environment
What are some ways you can assess for circulation?
level of consciousness, skin color and temp, pulse and chacter
A patient only has a carotid pulse, ballpark their BP
60mmHg
A patient has a femoral pulse but not a radial, ballpark their BP
70mmHg
A patient has a radial pulse, ballpark their BP
at least 80mmHg
How can we assess for D - disability in the ABCDEs
baseline neurologic evaluation - GCS, pupillary response
Why do we do E - expose/environment during ABCDEs?
we completely undress he patient to prevent hypothermia and missed injuries
what is a high riding prostate?
urethra is torn, prostate feels higher than normal
is it okay to do a foley on someone with a high riding prostate?
no its contraindicated! their urethra is torn!
malgaigne fracture
(the penis points the the pathology)
what is DPL and what is it indicated for?
diagnostic peritoneal lavage. It is indicated in the evaluation of intraabdominal trauma specifically the small bowel(bleeding, perforation) (Note: Spiral CT of the abdomen has largely replaced DPL as an initial screening tool for intraabdominal trauma in the emergency setting.)
Pt wit fractured cribriform plate needs gastric tube, should you go NG or OG?
OG unless you want to stick it in their brain
What is included in the primary survey?
ECG, vitals, ABGs, SpO2 and CO2, urinary/gastric tubes, urinary output
what are the components of the secondary survey?
H&P including neuro, special diagnostic tests and reevaluation
when do you start secondary survey?
after primary survey! and ABCDEs are reassessed and vitals are RETURNING TO NORMAL
What is AMPLE?
allergies, medications, past illness, last meal, events/environment/mechanism
What volume hemothorax goes straight to the OR?
1500mL
In penetrating trauma should you just remove the object?
No! get proximal and distal control of the blood supply and then remove
During secondary survey of the head what do you want to do?
external exam, scalp palpation, eye and ear (watch for visual acuity, periorbital edema and occluded auditory canal)
what is zone 1 of the neck? and what do you have to worry about injury to this area?
sternal notch to cricoid – worry about the LUNGS, trachea, esophagus, spine, vertebral and PROXIMAL carotid arteries, and MAJOR THORACIC VESSELS. do CT angio, esophageal bronchogram
What muscle when penetrated would make you assume significant injury has occurred in the neck?
The platysma
What is zone 2 of the neck and what do you have to worry about in this area?
cricoid to angle of the mandible. worry about risks the carotid and vertebral arteries, jugular veins, esophagus, spine, LARYNX, and trachea. Zone 2 seems to be the easiest for surgical control
What is zone 3 of the neck and what do you have to worry about in this area?
angle of mandible and up. The DISTAL carotid and vertebral arteries, PHARYNX, and spine are all at risk.
What are some findings we look for in the neck (soft tissues)?
crepitus, hematoma, stridor, bruit
What do you need to do before Foley cath placement in injured patients?
DRE
Which of the following is the progression of shock?
a) Inadequate O2 –> Catecholamine surge –> Anearobic metabolism –> Cellular dysfunction –> Cell death
b) Catecholamine surge –> Inadequate O2 –> Anearobic metabolism –> Cellular dysfunction –> Cell death
c) Cell death –> Catecholamine surge –> Inadequate O2 –> Anaerobic metabolism –> Cellular dysfunction
d) Cellular dysfunction –> Cell death –> Catecholamine surge –> Inadequate O2 –> Anerobic metabolism
a) inadequate O2–>catecholamines–>anearobic metabolism–>cellular dysfunction–>cell death
What are signs of shock?
Altered LOC, anxiety, cold, diaphoretic, tachycardia, tachypnea (shallow), hypotensive, decrease urinary output
What are nonhemorrhagic shock examples?
tension pneumothorax, cardiac tamponade, cardiogenic, septic, neurogenic
What are hemorrhagic shock examples?
blood or fluid loss
how do you locate bleeding?
physical exam and diagnostic adjuncts (CXR, pelvic X-ray, FAST/DPL)
Which of the following is not included in the mnemonic “blood on the floor and four places more” when referring to looking for blood in 4 places.
a) Chest
b) Abdomen
c) Retroperitoneum
d) Spinal Column
e) Pelvis/Thigh
d) Spinal column
Bleeding interventions?
direct pressure/tourniquet, reduce pelvic volume, operation, splint fracture, angioembolization
What is 750mL (15%) or less BVL (blood volume loss) considered?
class I hemorrhage
What are signs of class I hemorrhage?
Slightly anxious, Normal BP, HR < 100, RR 14-20, UOP (urine output) 30 mL/h
How do you treat Class I hemorrhage?
crystalloid
What is 750-1500mL (15-30%) BVL considered?
Class II hemorrhage
What are signs of class II hemorrhage?
Anxious, Normal BP, HR > 100, Decreased pulse pressure, RR 20-30, UOP 20-30 mL/h
How do you treat Class II hemorrhage?
Crystalloid and possibly blood
What is 1500-2000mL (30-40%) BVL considered?
Class III hemorrhage
What are signs of class III hemorrhage?
Confused, anxious, Decreased BP, HR > 120, Decreased pulse pressure, RR 30-40, UOP 5-15 mL/h
How do you treat class III hemorrhage?
crystalloid, blood components, operation
What is >2000mL (>40%) BVL considered?
class IV hemorrhage
What are signs of class IV hemorrhage?
Confused, lethargic, Hypotension, HR > 140, Decreased pulse pressure, RR >35, oliguria
How do you treat class IV hemorrhage?
definitive control, blood products
what defines flail chest?
3 or more consecutive ribs in 2 or more places. watch for paradoxical breathing
what are the immediate life-threatening chest injuries?
laryngeotracheal injury/airway obstruction, tension pneumo, open pneumo, flail chest, pulmonary contusion, massive hemothorax (more than 1500mL) cardiac tamponade
what are signs of airway obstruction?
hoarse, quiet voice, noisy breathing, stridor
A pt presents in respiratory distress and shock via EMS. They have distended neck veins, one-sided decrease in breath sounds with hyper resonance and cyanosis. What is your next step?
Needle decompress ASAP 2nd interspace MCL to the side with decreased breath sounds
What is more likely from blunt trauma: tension pneumothorax or cardiac tamponade?
Blunt = tension pneumothorax
Penetrating = cardiac tamponade
how do you treat open pneumothorax?
With a partially occlusive dressing (3 sided)
how do you treat a flail chest/pulmonary contusion?
O2, re-expand lung, possibly intubate, FLUIDS!, analgesia
A 16 y/o M patient sustained a severe force to fracture ribs 1-3, is this bad?
yup, they will likely have associated injuries that have high mortality rates
A 23 y/o kung fu master broke ribs 4-9 in his opponent with a flying sidekick, what is his opponent at risk for?
pulmonary contusion (takes 12-24 hours to show on CXR but CT is much quicker) and pneumohemothorax.
Chuck norris round-house kicked you in ribs 10-12 and fractured them, what type of injuries are you at risk for?
abdominal injury
(4-9 = pulmonary contusion)
(10-12 = abdominal injury)
How do you treat recurrent pneumothoraces?
talc (chemical) pleurodesis
Hemoptosis with recurrent pneumothorax in a 35 y/o female should make you think of?
Catamenial endometriosis causing a pneumothorax
what are 3 indications for surgical intervention in a hemothorax?
- more than 1500cc
- more than 200-250cc/hr blood loss
- hemodynamically unstable
What are some x-ray findings that may indicate aortic tear ***
Widening of the mediastinum
Blurring of the aortic knob
Left pulmonary cap – fluid on left side
Deviation of the trachea or the esophagus to the right (NG tube)
Angle of the left main-stem bronchus greater than 140 degrees
Obliteration of the pulmonary aortic window
Fracture of the first and second ribs
A 77 y/o F presents with hypotension, JVD and when you listen to her heart, you have a double check your stethoscope to make sure you are on the diaphragm because you can’t hear shit. You try to feel for a pulse, what do you feel? Every time she breathes in, you see an increase in jugular venous pulsations, what is this called? Oh snap they, you don’t feel a pulse, if you had an ECG what would they probably have?
electrial alternans, pulsus paradoxus. It is called Kussmaul’s SIGN. they could have PEA if the tamponade was large enough. remember tamponade happens more in penetrating trauma
When should an ED thoracotomy be performed?
penetrating chest trauma patients who are hemodynamically unstable and those who demonstrated signs of life (palpable pulse, a blood pressure, pupil reactivity, any purposeful movement, organized cardiac rhythm, or any respiratory effort) either in the field or ED, but subsequently deteriorated.
What are the chances of being killed if you are ejected vs not-ejected from the car?
300 times
T/F each entrance and exit wound should be marked by the ED staff as entrance and exit.
False, they should be called gunshot 1, 2, 3…
T/F if someone committed suicide, you need to paper bag the hand.
True
What is the most commonly injured intra-abdominal organs?
spleen (40-55%) followed by liver (35-45%) and lastly bowel (5-10%)
What is the order of abdominal physical exam?
inspect, auscultate, percuss, palpate
why do we insert urinary cath before DPL?
to decompress bladder, monitor urinary output
Is DPL therapeutic?
Nope, it’s diagnostic
The hepatorenal recess or subhepatic recess is the space that separates the liver from the right kidney is also known as ________________
Morison’s pouch
What is another name for laparotomy?
celiotomy
A pt suffered from abdominal blunt trauma. During DPL, he had less than 100,000 RBC/mm3, is this positive or negative?
negative, a positive in blunt force is considered greater than 100,000 RBC/mm3
what is considered positive for DPL in penetrating trauma?
greater than 5,000 RBC/MM3
T/F: In penetrating trauma to the abdomen, you should just Betadine solely the abdomen.
False! go down to the knees in case you need the saphenous vein
(knees to nipple line)
what are battle signs a sign of? Do they need a CT?
basilar skull fracture! yes CT!!
what is an abbreviated laparatomy used for?
to control the damage that would otherwise have been caused by swelling in the abdomen. do surgery, leave belly open, close it all up after swelling has gone down–> compartment syndrome avoided. you are a certified badass
at what gcs would you intubate?
8 intubate
What is the monroe-kellie doctrine?
The pressure-volume relationship between ICP, volume of CSF, blood, and brain tissue, and cerebral perfusion pressure (CPP
What is considered an abnormal ICP? severe?
more than 20mmHg = abnormal. more than 40 = severe
What is cerebral perfusion pressure?
CPP = MAP - ICP
What is an uncal herniation?
a common subtype of transtentorial herniation, the innermost part of the temporal lobe, the uncus, can be squeezed so much that it moves towards the tentorium and puts pressure on the brainstem, most notably the midbrain
what is the most common location of intracerebral hematoma/contusion.
frontal/temporal lobes
Do conscious patients with intracerebral hematoma/contusions need operations?
most of them do not
Where does a coup injury occur? where do a countercoup injury occur?
coup = injures where the brain is impacted. countercoup injures where the brain bounces off the skull on the opposite side of the impact.
T/F Cerebral contusions and hematomas are frequently progressive injuries, and contusions may coalesce into hematomas. For this reason, repeat CT scans are important to follow the patient’s progress.
True!
What is the GCS of a mild brain injury?
13-15. x ray or CT
What is the GCS of a moderate brain injury?
9-12. CT scan for all
What is the GCS of a severe brain injury?
3-8. evaluate and resuscitate!
What are the indications for CT scan of the head?
GCS score still < 15 two hours after injury Neurologic deficit Open skull fracture Sign of basal skull fracture Extremes of age “Dangerous mechanism” Retrograde amnesia > 30 minutes in duration Severe headache Vomiting > 2 episodes
What is the management of a pt with signs of tentorial herniation?
Mannitol 0.25-1.0g/Kg IV bolus
Where do you want to keep a head traumas pts PaCO2 and BP?
paCO2 near 35 mmHg Bp more than 90
hypotension and bradycardia, a GCS 15, and no movement in extremities should make you think of what type of shock?
neurogenic shock
We want to avoid two things in head trauma pt (in relation to vitals)
- Hypo_______
- Hypo_______
hypoxia and hypothermia
Why do we do a DRE on spinal injury pts?
to see if they have voluntary rectal tone. If they don’t, that signifies a spinal cord injury.
(Stick your finger in there, and ask them to squeeze their buttcheeks)
is it cool to leave a patient on a board for 10 hours?
no, they can get rhabdo!
(it also can cause distracting pain making it impossible to rule out distracting injury when trying to clinically rule out spinal insult)
T/F: Drugs/ETOH/other injuries can mask spinal injuries
True!
Does a patient need a C-spine X-ray if they are cooperative, pain-free and able to concentrate on their c-spine?
No they do not need a c-spine xray
What makes a good lateral C-spine film?
You want to be able to see all 7 C-spine and the interspace between C7 and T1
When do you need an X-ray of the c-spine?
altered mental status
A bone fracture of the anterior and posterior arches of the C1 vertebra is what type of fracture?
A Jefferson’s fracture
What is an type 1 odontoid (dens) fracture?
Extends through the tip of the dens. This type is usually stable.
What is an type 2 odontoid (dens) fracture?
Extends through the base of the dens. It is the most commonly encountered fracture for this region of the axis. This type is unstable and has a high rate of non-union.
What is an type 3 odontoid (dens) fracture?
Extends through the vertebral body of the axis. This type can be stable or unstable and may require surgery
What is a hangman’s fracture?
fracture of both pedicles or pars interarticularis of the axis vertebra (C2)
What is a clay shoveler’s fracture?
stable fracture through the spinous process of a vertebra occurring at any of the lower cervical or upper thoracic vertebrae, classically at C6 or C7.
C1: Jeffersons
C2: Hangmans
C6/7: Clay Shovelers
When is flexion/extension X-ray indicated?
When concern persists about ligamentous cervical spine injury despite negative routine c-spine xrays in an alert and cooperative patient
cross-table lateral film excludes ________ % of fractures?
85%
(its basically a lateral view of any xray in a supine patient who cannot sit/stand, the image will include contralateral structures and make a diagnosis such as a fracture difficult)
What 3 plain film views should you get when screening for spinal injury?
AP, Lateral, and Odontoid (ie, open-mouth) views at a minimum.
T/F: 10% of pts with a c-spine fracture also have an associated noncontiguous vertebral column fracture
True!
What is the difference between complete vs incomplete spinal injuries?
complete = no motor or sensory below injury
incomplete = some motor or sensory bellows injury and residual sacral function
What is this reflex called and why do we use it?
Bulbocavernosus Reflex. The reflex is spinal mediated and involves S2-S4. The absence of the reflex without sacral spinal cord trauma indicates spinal shock and/or Cauda Equina syndrome.
what are two good treatments for neurogenic shock?
- fluid resuscitation
- possibly atropine and vasopressors
flaccidity and loss of reflexes shortly after cord injury is what type of shock?
spinal shock
Rib fracture/flail chest
Pulmonary contusion
epidural hematoma
uncal herniation too at the white arrow
subdural hematoma with midline shift and mass effect
Large frontal intracerebral hematoma with shift
Normal CT
Diffuse brain injury
hemothorax
